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Member rights and responsibilities

Understanding your health plan is important. You have rights and responsibilities as a member of Aetna Better Health® of Virginia Medallion (Medicaid), FAMIS or CCC Plus plans. We’ll help you understand your plan, so you can make smart health care choices.

Your rights

Your rights

As a member of our health plan, you have the right to:

 

  • Be informed of Aetna Better Health and all covered services
  • Receive information about Aetna Better Health, our services, doctors, other providers, and member rights and responsibilities
  • Be treated with respect, dignity and the right to privacy
  • Choose your personal Aetna Better Health doctor/primary care provider (PCP)
  • Change your Aetna Better Health primary care provider (PCP)
  • Receive information and treatment that is considerate of your cultural or ethnic background
  • Be treated regardless of race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment
  • Expect all information about your health to be confidential and to have your privacy protected
  • Not have your medical records shown to others without your approval, unless allowed by law
  • Receive information from your doctor about treatment options or other types of care available to you, appropriate to your condition, and explained in a way you can understand
  • Receive services from out of network doctors/providers
  • Obtain emergency care without prior approval from Aetna Better Health or your PCP regardless of whether the emergency care facility is in the Aetna Better Health network
  • Receive a second opinion on a medical procedure from an in-plan doctor/provider. If an Aetna Better Health provider is not available, we will help you get a second opinion from a nonparticipating provider at no cost to you
  • Participate with your doctor/provider in making decisions about your health care
  • Tell the doctor/provider that you do not want treatment, and be told what may happen if you do not have the treatment. You can continue to get Medicaid and medical care without any repercussions even if you say no to treatment
  • Make an official complaint or grievance about Aetna Better Health or file an appeal if you are not happy with the answer to your question, complaint/grievance, or care given. You can call the Managed Care HelpLine at 1-800-643-2273 or TDD 1-800-817-6608.
  • Appeal any decision made by Aetna Better Health directly to the Department of Medical Assistance Services (DMAS)
  • Know the cost of care you may be responsible for, including copays or services that Aetna Better Health does not cover
  • Be told in writing by Aetna Better Health when any of your health care services requested by your PCP are reduced, suspended, terminated or denied. You must follow the instructions in your notification letter.
  • Have you and/or your child’s doctor/provider tell you about treatment choices you may have, no matter what the cost or benefit coverage
  • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation
  • Find out what is in your medical records and request that they be corrected or amended
  • Request a copy of your medical records
  • Exercise your rights and to know that you will not have any retaliation against you by Aetna Better Health, any of our doctors/providers or state agencies
  • Access to health care services and medical advice twenty-four (24) hours a day, seven (7) days a week, including urgent and emergency services
  • Get family planning services from any participating Medicaid provider without prior authorization
  • Get information in different formats (i.e., large print, Braille, etc.), at no cost to you, if needed and in an easy form that takes into consideration the special needs of those who may have problems seeing or reading
  • Receive reasonable accommodations to ensure you can effectively access and communicate with providers, including auxiliary aids, free interpreters if you speak another language or are hearing impaired, flexible scheduling, and physically accessible buildings and services
  • Make recommendations regarding our member rights and responsibility policy; by joining our Member Advisory Committee, for example
  • Receive information about advance directives and formulate or nullify advance directives. Advance Directives or Living Wills tell how to have medical decisions made for you if you are not able to make them for yourself.
  • Ask for a description of all types of payment arrangements that we use to pay providers for health care services

Your responsibilities

Your responsibilities

As a member of our health plan, you are responsible for:

 

  • Reading the member handbook. It tells you about Aetna Better Health services and how to file a complaint or grievance
  • Schedule wellness checkups. Members under twenty-one (21) years of age need to follow the Early Periodic Screening Diagnosis and Treatment [EPSDT] schedule.
  • Get care as soon as you know you are pregnant. Keep all prenatal appointments.
  • Carrying with you and showing your Aetna Better Health identification (ID) card to each doctor before getting health services
  • Protecting your member ID card and not sharing it with others
  • Getting medical care from providers in our network
  • Knowing the name of your assigned PCP
  • Telling the doctor that you and/or your child are/is a member of Aetna Better Health at the time that you speak with the doctor’s office
  • Keeping doctor’s appointments or calling to cancel them at least twenty-four (24) hours ahead of time
  • Using the emergency room (ER) for true emergencies only
  • Learning the difference between emergencies and when you need urgent care
  • Treating the doctors/providers, staff and people providing services to you with respect
  • Giving all information about your health to Aetna Better Health and your doctor in order to provide care
  • Telling the doctor if you do not understand what they tell you about your health so that you and your doctor can make health plans together
  • Following what you and your doctor agree to do including making follow up appointments, taking medicines and following your doctor’s care instructions
  • Telling Aetna Better Health and DMAS when your address changes
  • Telling Aetna Better Health about changes in your family that might affect your eligibility or enrollment such as family size, employment, and moving out of the state of Virginia
  • Telling Aetna Better Health if you have other health insurance, including Medicare
  • Giving your doctor a copy of your Living Will and/or Advance Directive
  • Learning about prescription drugs and reasons for taking them
  • Letting Aetna Better Health know how we can work better for you 

 

DMAS pays us a monthly premium for your Aetna Better Health coverage. If you are found not eligible for Aetna Better Health coverage for past months because you did not give truthful information to your case worker or tell your case worker about changes in your circumstances, you may have to pay DMAS back for these premiums even if you do not get medical services under Aetna Better Health benefits during these months.

Your rights

Your rights

It is the policy of Aetna Better Health of Virginia to treat you with respect. We also care about keeping a high level of confidentiality with respect for your dignity and privacy. As a CCC Plus member, you have certain rights. You have the right to:

 

  • Receive timely access to care and services
  • Take part in decisions about your health care, including your right to choose your providers from Aetna Better Health network providers and your right to refuse treatment
  • Choose to receive long-term services and supports in your home or community or in a nursing facility
  • Confidentiality and privacy about your medical records and when you get treatment
  • Receive information and to discuss available treatment options and alternatives presented in a manner and language you understand;
    Get information in a language you understand - you can get oral translation services free of charge
  • Receive reasonable accommodations to ensure you can effectively access and communicate with providers, including auxiliary aids, flexible scheduling, physically accessible buildings and services and free interpreter services if you speak another language or are hearing impaired
  • Receive information necessary for you to give informed consent before the start of treatment
  • Be treated with respect and dignity
  • Get a copy of your medical records and ask that the records be amended or corrected
  • Be free from restraint or seclusion unless ordered by a physician when there is an imminent risk of bodily harm to you or others, or when there is a specific medical necessity. Seclusion and restraint will never be used as a means of coercion, discipline, retaliation, or convenience.
  • Receive information and treatment that is considerate of your cultural or ethnic background
  • Get care without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment
  • Be informed of where, when and how to obtain the services you need from Aetna Better Health, including how you can receive benefits from out-of-network providers if the services are not available in Aetna Better Health’s network
  • Know the cost of care you may be responsible for, including copays or services that Aetna Better Health does not cover
  • Obtain emergency care without prior approval from Aetna Better Health or your PCP regardless of whether the emergency care facility is in the Aetna Better Health network
  • Complain about Aetna Better Health to the State. You can call the CCC Plus Helpline at 1-844-374-9159 or TDD 1-800-817-6608 to make a complaint about us
  • Appoint someone to speak for you about your care and treatment and to represent you in an Appeal
  • Receive information about advance directives and formulate or nullify advance directives in the instance that you are not able to make your own health care decisions. See Section 17 of your member handbook for information about Advance Directives. 
  • Change your CCC Plus health plan once a year for any reason during open enrollment or change your MCO after open enrollment for an approved reason. Reference Section 2 of your member handbook or call the CCC Plus Helpline at 1-844-374-9159 or TDD 1-800-817-6608 or visit the website at cccplusva.com for more information.
  • Appeal any decision by Aetna Better Health that you disagree with that relates to coverage or payment of services
  • File a complaint about any concerns you have with our customer service, the services you have received, or the care and treatment you have received from one of our network providers. See Your Right to File a Complaint in Section 15 of your member handbook.
  • To receive information from us about our plan, your covered services, providers in our network, and about your rights and responsibilities
  • To make recommendations regarding our member rights and responsibility policy, for example by joining our Member Advisory Committee
  • Exercise your rights and to know that you will not have any retaliation against you by Aetna Better Health, any of our doctors/providers or state agencies

 

Your right to be safe

 

Everyone has the right to live a safe life in the home or setting of their choice. Each year, many older adults and younger adults who are disabled are victims of mistreatment by family members, by caregivers and by others responsible for their well-being. If you, or someone you know, is being abused physically, is being neglected, or is being taken advantage of financially by a family member or someone else, you should call your local department of social services or the Virginia Department of Social Services' 24-hour, toll-free hotline at 1-888-832-3858. You can make this call anonymously; you do not have to provide your name. The call is free.

 

They can also provide a trained local worker who can assist you and help you get the types of services you need to assure that you are safe.

 

Your right to confidentiality

 

Aetna Better Health will only release information if it is specifically permitted by state and federal law or if it is required for use by programs that review medical records to monitor quality of care or to combat fraud or abuse.

 

Aetna Better Health staff will ask questions to confirm your identity before we discuss or provide any information regarding your health information.

 

We understand the importance of keeping your personal and health information secure and private. Both Aetna Better Health and your doctors make sure that all your member records are kept safe and private. We limit access to your personal information to those who need it. We maintain safeguards to protect it. For example, we protect access to our buildings and computer systems. Our Privacy Office also assures the training of our staff on our privacy and security policies. If needed, we may use and share your personal information for “treatment,” “payment,” and “health care operations.” We limit the amount of information that we share about you as required by law. For example, HIV/AIDS, substance abuse and genetic information may be further protected by law. Our privacy policies will always reflect the most protective laws that apply.

 

Your right to privacy

 

We are required by law to provide you with the Notice of Privacy Practices. This notice is included in your member packet and our member newsletter. This notice informs you of your rights about the privacy of your personal information and how we may use and share your personal information. Changes to this notice will apply to the information that we already have about you as well as any information that we may receive or create in the future. You may request a copy at any time by calling Member Services at 1-855-652-8249.

 

In your doctor’s office, your medical record will be labeled with your identification and stored in a safe location in the office where other people cannot see your information. If your medical information is on a computer, there is a special password needed to see that information.

 

Your medical record cannot be sent to anyone else without your written permission, unless required by law. When you ask your doctor’s office to transfer records, they will give you a release form to sign. It’s your doctor’s office's responsibility to do this service for you. If you have a problem getting your records or having them sent to another doctor, please contact our Member Services at 1-855-652-8249 (TTY/TDD: 711 or 1-800-828-1120).

 

Our Member Services department will help you get your records within 10 working days of the record request.

We will assist you:

 

  • To provide quick transfer of records to other in- or out-of-network providers for the medical management of your health
  • When you change primary care providers, to assure that your medical records or copies of medical records are made available to your new primary care provider

If you would like a copy of your medical or personal records, you may send us a written request. You may also call Member Services at 1-855-652-8249 (TTY/TDD: 711 or 1-800-828-1120) and ask for a form that you or your representative can fill out and send back to us. You have a right to review your requested medical records and ask they be changed or corrected.

Your responsibilities

Your responsibilities

As a member, you also have some responsibilities.

 

  • Read the member handbook. It tells you about Aetna Better Health services and how to file a complaint or grievance. 
  • Present your Aetna Better Health of Virginia Membership card whenever you seek medical care.
  • Provide complete and accurate information to the best of your ability on your health and medical history.
  • Participate in your care team meetings, develop an understanding of your health condition, and provide input in developing mutually agreed upon treatment goals to the best of your ability.
  • Adhere to what you and your doctor agree to do, including making future appointments, taking medicines and following your doctor’s care instructions.
  • Keep your appointments. If you must cancel, call as soon as you can.
  • Receive all of your covered services from Aetna Better Health of Virginia’s network.
  • Obtain authorization from Aetna Better Health of Virginia prior to receiving services that require a service authorization review.
  • Call Aetna Better Health of Virginia whenever you have a question regarding your Membership or if you need assistance toll-free at one of the numbers below.
  • Tell Aetna Better Health of Virginia when you plan to be out of town so we can help you arrange your services.
  • Use the emergency room only for real emergencies.
  • Call your PCP when you need medical care, even if it is after hours.
  • Tell Aetna Better Health of Virginia when you believe there is a need to change your plan of care.
  • Tell us if you have problems with any health care staff by calling Member Services.
  • Tell Aetna Better Health about changes in your family that might affect your eligibility or enrollment such as family size, employment, and moving out of the state of Virginia.
  • Call Member Services at one of the phone numbers below about any of the following:


    • Aetna Better Health Member Services 1-855-652-8249TTY/TDD 711 or 1-800-828-1120; 24 hours a day, 7 days a week. The call is free.


      • If you have any changes to your name, your address, or your phone number. Report these also to your caseworker at your local Department of Social Services.
      • If you have any changes in any other health insurance coverage, such as from your employer, your spouse’s employer, or workers’ compensation.
      • If you have any liability claims, such as claims from an automobile accident.
      • If you are admitted to a nursing facility or hospital.
      • If you get care in an out-of-area or out-of-network hospital or emergency room.
      • If your caregiver or anyone responsible for you changes.
      • If you are part of a clinical research study.
 

Questions?

We can help

You can call your Member Services department anytime. 

Contact us

You can also check your member handbook for answers. Just visit our materials and forms page.

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